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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 East Hazelton Avenue, Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.org/ehd PUMP INSPECTION CHECK LIST Address: 7 l� 1 lti i � : L d4 Permit#: 7 I .l" > Inspe tion ate: Z _j1 I Parameter/Standard Meets SJC Standards? Comments/Measurements/ Recommendations CEMENT PEDESTAL: Dimensions of surface seal 2'x2'x4" minimum Yes.] No ❑ NA ❑ Casing extends at least 12" above grade Yes Efr No ❑ NA ❑ Casing extends at least 1" above pedestal Yes [T No ❑ NA ❑ Free of cracks/contiguous with annular seal Yes r No ❑ NA [:1 Graded to allow drainage away from casing Yes fl No ❑ NA ❑ SANITARY SEAL: Well is sealed between pump and casing Yes ❑ No ❑ NA ❑ Seal between all pipe columns and casing Yes ❑ No ❑ NA ❑ Sounding tube/air vents sealed properly Yes El No ❑ NA ❑ Chlorination port available and sealed properly Yes e] No ❑ NA ❑ SAMPLE TAP AND BACKFLOW PREVENTION: Non -threaded sample tap between well head and check valve or within 3' of well head Yes P" No [:1 NA ❑ Adequately installed check valve or BFP device Yes -E] No ❑ NA ❑ Any cross connections? (ex: chemical feeders hooked to distribution system/ag flood irrigation from domestic supply) Yes ❑ No ❑ NAS] Air gap of at least 6" same as pipe diameter) Yes B No ❑ NA ❑ MAINTENANCE: Well/Pump visible and protected from damage Yes 0 No ❑ NA ❑ Well/Pump free from excessive vegetation Yes.2 No ❑ NA ❑ MISCELLANEOUS: Permit drawing represents actual location of well Yes 0 No ❑ If 'no' is selected, attach an accurate map to permit Permit drawing sufficient to locate well in future Yes Er No ❑ Photograph taken and attached to record Yes ❑ No OTHER: Comments: Inspected By: Title: V� Received By: Date: EH -4200- 8/31/2015